Ethically Managing Risks in Global Health Fieldwork: Human Rights Ideals Confront Real World Challenges

Rachel Hall-Clifford and Robert Cook-Deegan

Abstract

Global health is an interdisciplinary field engaged with implementation of the human right to health, yet ethical dimensions of the on-the-ground realities of this work have been underexplored. Fieldwork in global health produces knowledge through both primary research and the lessons of practical program implementation. Much of this essential knowledge, which often documents health disparities and other human rights abuses, arises from work in dangerous contexts. Work in such environments entails risk to all participants in the global health enterprise, both local and foreign, but affects them differently. The risks of ethical fieldwork must be considered not only for the well-being of project participants and fieldworkers but also in light of how they shape and constrain global health research and program implementation. Drawing on case examples from the authors’ fieldwork, this article marks an effort to begin disentangling the realities of risks in the field and the responsibility borne by the fieldworker to undertake ethical action, recognizing that decisions are often made without established protocols or the immediate availability of guidance from colleagues. We call for further engagement within global health on ethical issues distinctive to the complex and dangerous places in which the promise of a right to health is enacted in the real world.

Introduction

The cobblestones up the hill to “my” family’s house in a highland Guatemalan town always felt satisfying under my feet as I walked homeward in the late afternoons. Alternately warmed by the sun or slick with rain depending on the season, they led home, past friends and neighbors to be greeted along the way. I reveled in the feeling of belonging that marks accomplishment as a fieldworker. The physical exertion of the climb was gratifying after a day spent on the far less concrete efforts of interviewing, observing, and doing surveys about children’s access to primary health care services. The members of the family with whom I lived energized me, quickening my steps toward the warmth of the stove and evening conversations. They were indigenous, mobilized, and brilliant.

More than 20 years after the Guatemalan peace accords ended a decades-long genocidal civil war, rates of ethnic violence remain high. My adopted family was torn apart when an adult son was assassinated for being an activist. His body bore the testament that the indigenous must know their place—his tongue cut out, his brain bashed in as a visceral message to silence those who challenge the status quo. The family spent a frantic evening searching for him when it became apparent he had been taken, their feet flying over those same well-worn cobblestones. They found him clinging to life in a ditch at dawn; there was no time to save him, only to glimpse his incredible suffering and say inadequate goodbyes.

Following the assassination, I received a few anonymous threatening voicemails and stayed physically away, an option I was very aware of having but which the family did not. Years of grief and indecision followed. The family ultimately decided not to pursue prosecution of the murder in the face of futility and fear of reprisals. Beyond my sadness at the loss of my friend, I feel guilt, however misplaced or even self-aggrandizing, that my projects and shared passion for indigenous causes may have helped invite trouble. My beloved daily journey to their door, when reconsidered, becomes a pale flag marking with each wave an invitation to deadly scrutiny.

Though an extreme example, this fieldwork experience of the first author illustrates that well-intentioned and carefully implemented fieldwork can expose local partners, participating communities, and fieldworkers themselves to unforeseen and disastrous outcomes. Fieldwork in global health, rooted in the advancement of health as a human right, is intended to produce knowledge through both primary research and the empirical lessons learned through program implementation. Much of this knowledge—whether illustrating health disparities, documenting abuses committed against people, or describing factors that undermine the capabilities needed to lead a fully realized human life—is gained by gathering data in dangerous places. This work entails risk to global health fieldworkers and to those around them. Those risks are often confronted with little or no training, based on an implicit assumption that dangers can be successfully and ethically navigated by the fieldworker. Failures to do so have no formal place in reporting global health project outcomes, and community participants and fieldworkers can be left to grapple with the aftermath without systematic support. Beyond an unfulfilled responsibility for the well-being of fieldworkers and project collaborators and communities, global health must also account for the ways in which the knowledge that informs goal setting and principles of practice is shaped by the risks and ethical challenges of fieldwork.

An exhaustive taxonomy of the practical and ethical challenges of fieldwork is infeasible, given the wildly diverse situations in which global health and human rights workers may find themselves. Yet anticipating potential risks to fieldworkers and their project communities can help mitigate them. Risks faced by fieldworkers arise through the possibility of causing harm to others and the possibility of harm to fieldworkers themselves. Firsthand accounts of fieldwork challenges have begun to emerge in the literature.1 In this article, we share examples from our own work in an effort to illustrate some of the gaps between ethical ideals and realities in the field. We focus on the experiences of fieldworkers in navigating the appropriate level of engagement and activism in project communities, implementation of informed consent in contexts of crisis, routine dangers in the field, and grappling with self-identity and morals in the field. We propose a global health ethics practice framework to systematically (1) anticipate the ethical issues likely to arise in fieldwork, (2) incorporate practical fieldwork skills and applied ethics into global health training, and (3) share ethics-related lessons learned from fieldwork in professional publications and discourse. This practice framework can help bridge the gap between particular field experiences and the abstract principles of research ethics through a focus on applications to real world contexts.

Background

Global health evidence and ethics

Global health is an interdisciplinary field drawing from academic disciplines across human rights, medicine, and the natural and social sciences. Perhaps due to this interdisciplinarity, global health has not settled on a coherent, cross-cutting set of theories to produce evidence through a formal inductive process as in other academic disciplines.2 From another interdisciplinary approach, human rights has grown from its roots in activism and law to include direct empirical observation, which often entails engagement with people who have been abused or are close to those who have been. Yet global health and human rights have both adopted forms of validating and disseminating data from the natural sciences. Standardized methods-results-conclusions publication formats often leave little place for the disclosure of fieldwork or implementation realities that muddle interpretations of the data presented. The data then form the evidence base for programmatic decisions and principles of practice.

Gaining valid data in contexts where security is uncertain and human rights are not respected is challenging.3 Discussions of global health fieldwork ethics tend to be abstract and separate from the reporting of results from particular projects. Most publications describe methods with little or no attention to the risks and challenges faced by fieldworkers or those with whom they work. This omission may be appropriate when conditions do not intrude on the fieldwork, but challenges should be explicitly addressed when the context limits the gathering of data, when methods taken to mitigate risks might influence outcomes, or when experiences might be used to educate future fieldworkers. Important emphasis has been made in recent years on the dissemination of research findings within project communities, though important questions about how to do so safely and ethically remain (see Mootz et al. in this issue).

Public health ethics tend toward the teleological, even utilitarian, as we attend to maximizing good and minimizing harm for populations as a collective.4 This tendency seems also to have shaped approaches to fieldwork, with vital, life-saving ends sometimes justifying less-than-ideal means when it comes to research and implementation in dangerous contexts. By nature, global health and human rights empiricism must cross geopolitical and cultural boundaries.5 Global health also confronts sociocultural differences and substantial power imbalances between fieldworkers and community participants.6 Significant work in the past two decades has been dedicated to improving methods of community participatory involvement in global health programs and establishing meaningful community engagement.7 Yet many of the risks in global health fieldwork continue to be borne by particular individuals or groups who may have little input in goal setting and study design of the global health programs that may put them at risk.8 Reckoning the costs and benefits of global health interventions in resource-constrained settings undoubtedly varies among individual, community, state, and international perspectives.9 Advancement of health as a human right, the principles of partnership, and the promotion of justice become even more challenging when we consider the uneven distribution of the risks of harm from global health programming.10 Confining attention to procedural ethics by meeting US Common Rule standards for informed consent, reciprocity, confidentiality, and conflicts of interest from funding sources limits consideration of the broader implications of the political and economic structures in which global health research takes place.11

Critical humanitarianism and the right to health

Though its programs are often framed as politically and morally neutral, global health is rooted in globalized notions of humanitarianism to enact the right to health.12 While global health focuses on making the right to health a reality via affordability, accessibility, availability, and quality, this mission is underpinned by the values of a dominant neoliberal geopolitical system.13 Responsibility for respecting, promoting, and fulfilling rights falls to states, leaving uncertainty about the extent of moral obligations across political jurisdictions.14 Peter Van Arsdale and Derrin Smith articulate three key principles of modern humanitarianism: benevolence, autonomy, and nonmaleficence, which resonate with our traditional notions of research ethics, but they caution that there has been no consensus among humanitarian fields of practice about how these ethical principles can be enacted.15

Relationships in global health are inherently asymmetrical due to the power differentials between the actors and institutions who are most often in positions of responsibility for setting and directing global health strategies and those who are positioned as recipients of their strategies.16 Global health programs and the human rights abuses they seek to remedy occur at both the local and global levels.17 Fieldworkers confront the entanglement of politics and compassion—the competing motivations embedded within relationships of giving—on the front lines of this intersection.18 Human solidarity has been positioned as a core principle for overcoming the inevitable inequalities of power and wealth inherent in interpersonal engagement in global health.19 However, questions remain about how such solidarity might be enacted in the field. It can obscure the motivations for global health interventions and for the engagement of individual fieldworkers with project objectives. Particular acts of solidarity may create greater risk for local project partners and fieldworkers, as in the opening example in this article. Given the complex and at times problematic nature of humanitarianism in creating sustainable improvements rooted in respect and mutuality, the challenges—moral, ethical, and practical—facing the individual fieldworker or project team on the ground are immense.

Methods

Our analysis draws on our experiences as fieldworkers in global health research, program implementation, and advocacy. Hall-Clifford has worked in Guatemala as a medical anthropologist and global health practitioner for nearly 15 years and has also contributed as a research scientist and consultant to projects in Africa and Eastern Europe. Cook-Deegan did medical humanitarian work in Central and South America early in his career, and then confronted ethical dilemmas again when on human rights missions to Central America, Turkey, and Iraq and through human rights advocacy at the national and international level. While we draw on our own particular experiences in the field via brief examples in order to illustrate our ideas for developing a practical fieldwork ethics framework, we believe these experiences resonate with those of others shared in the emergent literature and with the lived experiences of colleagues in the field.

Harm to others and responsible (in)action

Unintended harms

Global health is littered with examples of research projects and program strategies that had unintended outcomes, both good and bad.20 The good includes durable health delivery systems and community engagement, and the bad includes worsening the burden of disease, environmental calamity, and unforeseen sociopolitical consequences. Fieldwork has been a critical part of the burgeoning evidence base in global health and underpins its intervention design theory. Here, however, we concern ourselves with the sometimes dire, but often unacknowledged, consequences of interpersonal engagement of the fieldworker within communities and the attendant realities of research and project implementation. Clearly not all global health fieldworkers are outsiders to the communities in which they work. Often, marked inequalities of visibility and agency exist between foreign and national fieldworkers, and the two sets of actors may face very different dangers in field settings.21 National fieldworkers and community implementation teams are set apart and potentially made vulnerable by virtue of their involvement with projects connected via intellectual ancestry or funding to the broader, external global health or human rights polity.22

As described in the introduction, the Guatemalan field experience of the first author included unequivocal, irreversible harm for which she had little preparation or institutional support. The inescapable fact is that harm can come to community members through engagement with global health projects and their fieldworkers. In this case, the fieldworker was neither directly responsible for the violence directed at her friend and colleague nor even the source of his initial community-based programming and advocacy work. However, the excitement of sharing ideas and work was mutually encouraging but may also have led to risk taking that resulted in death. Moreover, the simple act of being seen working with a foreign researcher may have drawn the attention of the perpetrators. The sister of the person murdered told of the horror of that death and its repercussions:

[He] only ever worked for human rights; visiting communities, helping [people] know their rights. He did nothing wrong … Almost everyone [in town] knows who did it, but they can’t find witnesses. No one wants to testify, and how would the family feel if someone did and something happened? They didn’t just kill him, they tortured him. He was screaming. My mom didn’t want to live, couldn’t get out of bed.23

There was unfathomable loss to be borne by the family as they grappled with how to reengage with a terrifying new reality so at odds with all they had worked for in creating indigenous solidarity and the heartbreaking practicalities of supporting the deceased’s young child and pregnant widow. The indigenous community experienced a fresh cycle of suspicion and fear that was all too familiar from the days of the civil war, and community health and development projects were unsurprisingly hampered. The family eventually decided not to pursue prosecution of the assassination, feeling that it was futile, potentially too costly, and risky. His sister said a few years afterward, “Now we can have peace because we have let it go. It wasn’t good to have so much hate. My mother would see them [the perpetrators] in the street and want to kill them. It wasn’t good to have so much hate inside.”24 She took comfort in the idea of divine justice.

For the global health fieldworker in this instance, divine justice seemed a poor salve for such terrible mutilation of this well-loved family. Following the death, a flurry of calls and emails to lawyers and human rights organizations explored options and contemplated prosecutorial justice. It took years to recognize that these actions, while done in concert with the family, were not fulfilling their needs but rather those of the fieldworker to be active, to avenge, and even to expiate guilt. All of these experiences were well outside the preparation for fieldwork, despite training in social theory, research ethics, and protocols approved by institutional review boards. Conventional research ethics fell far short of preparing for, much less averting, a very real and tangible moral catastrophe, and the episode was not reported as part of the fieldwork, though some similar experiences were shared by an academic advisor working in the same region 30 years earlier.25 We surmise that bad things often happen during fieldwork that remain unreported, with unclear channels and few outlets to do so. A coherent global health ethics practice framework should include explicit attention to potential risks, training in anticipating and mitigating such risks, and reporting of field experiences alongside data.

Limitations of traditional research ethics

Further limitations of research ethics in the field are illustrated by two examples drawn from a human rights mission to Southeast Turkey in the weeks after poison gas attacks against the Kurds of northern Iraq in 1988.

A team of fieldworkers from Physicians for Human Rights came in October 1988, prepared with cameras and surveys to document the poison gas exposures that occurred in August, ten weeks before. The survey, translated into Kurdish, was based on a questionnaire designed years earlier by Canadian experts for the World Health Organization to elicit information about poison gas exposure. Interviews with those from northern Iraq, now housed in refugee camps in southeast Turkey, did indeed yield evidence of exposure to mustard gas.26 But while this provided information that was valuable at a time when there was little objective and credible evidence about the use of poison gas, the work included two mistakes. One was a failure to protect the camp residents who were interviewed in the camps—we published a photograph taken in a refugee camp that could be used to identify those who had spoken to us. We told residents we might use photographs and the survey information in publications, but they could not have foreseen that authorities might also use our own information to identify those who had helped us. To our knowledge, this did not occur, and we do know the whereabouts of those most likely to be targeted. Yet we also know that authorities were acquainted with our work, because an Iraqi expatriate journalist returned from London to northern Iraq and was executed; he had our report in his possession at the time he was arrested.

The other mistake was tactical but illustrates the ambiguous moral architecture of fieldwork in contexts where human rights are routinely violated.

After a first set of interviews and surveys in a refugee camp near Mardin, southeastern Turkey, the team was summoned to meet with the regional governor, who at the time had dictatorial powers because a five-state area was under martial law. He was an overt racist who spoke openly about Kurds as “dirty animals who live in caves,” and he had presided over grotesque atrocities. Amnesty International had reported the torture—and sometimes death—of detainees in a prison just a few blocks from where our interview took place in Diyarbakir.

When asked what we were doing in the region, as team leader, the second author of this paper noted that we were American doctors who wanted to assess the health of those who had been attacked in northern Iraq and were now in camps in southeastern Turkey. When I mentioned the use of a survey, the energy in the room suddenly changed, from superficial joviality to sudden awareness that our work was a real threat to the political interests of the regional governor. We were never granted access to another camp, and our rooms were broken into and my briefcase opened (and its contents presumably photographed). We had, however, deliberately left the briefcase with a few blank survey forms in the room, hiding the completed surveys, videotapes, and photographs on our bodies, and we also left some documentary material with a trusted colleague to independently ship back to us.

This mistake was entirely avoidable. Volunteering information about the use of a survey instrument was gratuitous in the moment of our interview with the regional governor. The failure to fully explain our methods would have indeed been taken by the authorities to be a deliberate withholding of pertinent information, but given the political context, revealing such details was a blunder that undermined the primary purpose of the human rights mission. The second author learned from this mistake, but the only others who also learned were members of the team and the Physicians for Human Rights staff who were immediately made aware of it by phone after the meeting was over.

This one mission thus entailed unnecessarily putting refugees at risk of identification in a region where human rights were notoriously violated, and gratuitously volunteering information that undermined the process of documenting poison gas attacks. Forethought and common sense could have avoided both mistakes. Training—and perhaps more regular sleep—would have made such forethought more likely, and might have avoided problems from occurring in the first place. In some respects, the digital data storage tools now available can reduce opportunities for breaches of confidentiality of physical data, but they introduce new vulnerabilities for keeping data secure and ways that field findings can be misused.

Enacting ethics

The two fieldwork examples described above highlight the troubling inability of traditional research ethics to offer adequate safeguards to local participants in global health projects. As the fieldworkers involved, we can unequivocally say that we undertook our projects with clear, ethics-approved protocols and also hold a deep commitment to ethical practice as fieldworkers. Even so, these experiences give us pause—not just in terms of how we responded in the field, but also as cautionary tales about the need for training to address ethical dilemmas likely to arise in fieldwork. The gaps in established norms and practical ethics relevant for global health have real consequences for our communities of research and practice. It is the murky interstitial spaces between clear-cut implementation of project protocols and the human realities of being in the field, often in unstable or violent contexts, that most concern us.

At the root of the many conundrums facing fieldworkers in navigating the practical ethics of global health fieldwork is the double bind of acting responsibly by avoiding doing either too much or too little. In the first case from Guatemala, the friend and colleague was not killed directly as a result of his engagement with the global health research project, but the presence of a foreign fieldworker drew attention to him and the family household. In retrospect, what seemed like encouragement of a friend and potentially useful community engagement was dangerous and pushed beyond the boundaries of acceptable activism for the place and time. Perhaps in such encouragement, the values of the fieldworker (and the broader agenda of social justice promoted by global health) took primacy over local realities. Here, the fieldworker likely did too much, going beyond the scope of an original project to encourage and support community activism.

In the second example, regarding Iraqi refugee camps, the fieldworker did too little to implement research consent processes and protections of subjects on the one hand and over-explained the project to local authorities on the other, undermining the very purpose of the fieldwork. Others considering fieldwork ethics have also contended that informed consent processes cannot appropriately be applied in situations where rights are being violated.27 Consider the interview with the regional governor in southeast Turkey described above. Was that interview with a human subject of research? Should that interview be governed by fully informed consent? Clearly not, since the purpose of the mission was to gather information that the governor was committed to suppressing. When and how to apply the tenets of human research protections in complex political contexts warrants training and informed anticipation. Non-intervention in the face of human rights abuses is unethical, but how appropriate action can best be undertaken and how such action can be adjudicated in the field are significant challenges.28

Risks to fieldworkers

Dangers in the field

Myriad risks confront global health fieldworkers. While some risks are the quotidian dangers faced by any relatively wealthy outsider to low-resource settings, others are specific to the nature of global health fieldwork. Challenges and risks are to be expected in undertaking work in politically unstable environments or conflict zones. Yet perhaps we prize the ability to navigate these challenges and risks as individuals too highly, above the development of cohesive norms of practice within global health. The ethos of fieldwork can embrace bravado and place trust in individual problem solving to navigate risky situations. The work of global health requires effective problem solvers in the field, but we should not allow fieldwork norms to be shaped by machismo or unconsidered risk. Fieldworkers by nature are perhaps drawn to adventure, decision making on the fly, or even the adrenaline rush of beating the odds of some particular risky barrier to the task at hand. Accounts of actions taken by fieldworkers in dangerous situations are typically shared only informally with colleagues, if shared at all, and have traditionally had little place in the global health literature. Such experiences are much more likely to be shared in the bar after conference proceedings than in the plenary.

In a promising development, accounts of fieldwork experiences and the “everyday violence” faced during them are increasingly being shared. The pressure to get results in dangerous and difficult circumstances can be intense, and the lines of what risks are appropriate become blurred.29 While such risks are not unique to high-risk settings, they are much more likely where violence is common. A nascent literature on fieldwork acknowledges dangers to the fieldworker that are likely common in many of the resource-constrained and unstable loci of global health practice, such as robbery, sexual assault, gun violence, and warfare.30 Even fewer pieces in the literature on long-term fieldwork focus on or even include practical strategies for maintaining personal safety in dangerous settings.31 How global health fieldworkers deal with threats to their safety seems to be understood as highly individualized, and the fear that such threats are likely to engender is largely unacknowledged. Singularly, Linda Green has described fear as a chronic condition endemic to her study communities in Guatemala, which limits movements and interactions for community members and the fieldworker.32

Our task becomes working from particular experiences toward shared principles. We cannot ignore the power and resource imbalances embedded within global health fieldwork. The threats to the first author in Guatemala, while frightening, felt vague and easily escaped in contrast to the ultimate consequence faced by her tortured and murdered local counterpart. The value of objectivity in bearing witness to suffering has limitations, and acknowledging shared pain or empathy helps us better understand the views, positions, and realities of local participants.33 Grappling with and acknowledging fieldworkers’ roles in research sites is vital to better understanding the realities from which our data emerge and disrupting the inequalities inherit within those relationships. Further, cultivating critical self-reflection—as individual fieldworkers and collectively—may assist global health in describing local realities in the context of global agendas, and may lend urgency to action against particular diseases and conditions, thus promoting humanitarian goals and supporting health as a human right.

The self in the field

Doing the work of global health often places fieldworkers in unfamiliar locations. Adaptability to diverse and new environments is an essential quality for successful fieldworkers, and the perils faced by them are not limited to those resulting in the loss of property or physical harm. Fieldworkers frequently bear the weight of witnessing what they cannot change and the onus of this ineffectuality.

In a very rural village where I conducted research in Guatemala, I listened each night as the three children in the household where I lived cried themselves to sleep from hunger. The first night, tears stung my eyes and anger swelled in my chest as the children’s mother yelled at them to shut up. I felt indescribable powerlessness that night and throughout my time in the village. I was one person with a small amount of grant money and could bring only a limited amount of food to the village—the most ineffectual of bandages. At the end of long days, hungry (but far from starving) from giving away my dinner, I would lie in my bed on the dirt floor and try to think of the bigger picture with ideas for possible improvements to rural health services, working to justify my meager offerings to this troubled place. All the same, I was repulsed when I eventually felt the words “shut up” rise to my own lips one night as the children cried incessantly in their hunger.

The idea of local moral worlds—where the deeply embedded context of place and time situate the morality of actions—is compelling.34 Particularly in long-term fieldwork in global health, the fieldworker may experience the dissonance of competing local moral worlds—those of the fieldsite(s) and those of the internal geographies of their own background. Satisfactory reconciliation of these two worlds can be elusive, rendering ethical responses to challenges and risks in the field difficult and marked by second-guessing. As Antonius Robben and Carolyn Nordstrom describe, “Existential shock is a highly personal and context-specific research phenomenon.”35

Reframing of one’s sense of self, identity, and notions of morality as a result of field experiences can leave fieldworkers with unanswerable ethical questions, even regret.36 What can or should have been done better? What culpability for poor outcomes from good-faith decisions made in the field, if any, do we bear? Is our presence in the field (with too much action or inaction) a waste of limited resources or, by extension, a collusion with structural violence and inequality? Liisa Malkki notes that those who undertake humanitarian work often do so because it makes them feel good or useful but are frequently left “feeling ambivalent, inadequate, and even impure about the work that they have done, despite their best efforts to fulfill the standards of their profession and their personal ethical commitments.”37 Dangerous, unanticipated events in the field can lead to post-traumatic stress disorder or other mental health concerns among fieldworkers, and few resources are allocated to these concerns within global health training programs and implementation organizations. There is often little support within the profession, either materially or interpersonally, to assist fieldworkers thus affected. The board of Physicians for Human Rights observed that those returning from missions frequently showed symptoms of post-traumatic stress disorder, exacerbated by sudden dissolution of the team that had an intense shared experience upon return. Is this a necessary condition of the work, or a feature to be recognized and addressed by anticipating it will occur and ensuring that the team remains in contact and has continued support? And what about fieldworkers who work alone? Making meaning from the lived experience of fieldwork should not be sidelined but rather integrated into our understandings of global health practice and the implementation science driving our work.

Discussion

We acknowledge that the concerns and perhaps even the fieldwork case examples presented here may be dismissed as a move toward navel-gazing or shifting focus from the genuine work of global health and human rights, to privilege the experiences of fieldworkers over those of project communities. Undoubtedly, innumerable additional challenges in fieldwork ethics and safety confront fieldworkers beyond those drawn from our examples. Despite these limitations, we nonetheless contend that integrating explicit attention to ethical complexities of fieldwork into the discourse of global health as an interdisciplinary field is essential to improving it, understanding the evidence base, and equitably defining and advancing global health objectives. Collegial relationships often prioritize swapping “war stories” as a way to process and decompress from difficult fieldwork, with limited opportunities for systematically understanding how one’s experiences articulate with those of others in the field. Surely, field experiences should be personally processed with the support of family, friends, and counsellors, but they must not simultaneously be divorced from our professional dialogue and reckonings of datasets. Rather, sharing stories of challenging fieldwork is a tool that can enhance practice in the field.

A global health ethics practice framework must be implemented to cohesively provide guidance on (1) the ethical issues likely to arise in global health fieldwork, (2) the practical fieldwork skills and applied ethics training needed by fieldworkers, and (3) the dissemination of ethics-related lessons learned from fieldwork within professional publications and discourse. The ethics challenges and risks facing both fieldworkers and project communities need to be explicitly recognized and addressed. An iterative ethics practice framework could do so by uniting ethical responsibilities with actual experiences in the field. As the examples in this article illustrate, fieldwork ethics must include workable strategies to safeguard communities that go beyond minimal adaptation of traditional research ethics for varied contexts, such as informed consent procedures, to a broader process through which core ethical principles can be made more concrete and relevant for local implementation. A global health fieldwork ethics practice framework would also create a foundation for building and sharing tools—examples of past problems, training materials, and open discourse on fieldwork realities—that would enable collective foresight in preparation for fieldwork.

Training in both traditional bioethics and engagement with practical ethical issues raised by global health fieldwork must be a part of the training of everyone engaged in global health—practitioners, academicians, and consultants. The establishment of global health ethics networks and training centers based in low- and middle-income countries could go a long way toward embedding ethics training and support for fieldworkers into research contexts.38 Supporting capacity building for local institutional review boards in low- and middle-income countries to enable relevant, responsive, and fair review of research as well as community-based participation in research and program goal setting could also help.39 As an interdisciplinary field of practice, global health must perhaps work harder than other traditional academic disciplines to understand the norms of its diverse contributing disciplines and create shared ethical guidelines that can be used in the sometimes dangerous contexts of fieldwork. Perhaps most importantly, more articles that include explicit attention to the ethical issues that arise in fieldwork, more use of case examples, and explicit attention to the issues in training for fieldwork can all contribute to a more robust framework ethical conduct of fieldwork. Knowledge, the evidence base, arises from the successes and failures of research, program implementation, and documentation. We must more readily acknowledge the human element of this work.

Training programs in global health must include more intentional training on common fieldwork risks and strategies for how to avoid them (for example, carry a decoy wallet for robbers, barricade the door of insecure sleeping quarters with a rubber door wedge, etc.). This received wisdom is potentially as valuable as traditional field methods. Global health ethics training must take advantage of the opportunity to link global health research and practice to notions of justice and to critically discuss what this may mean in field contexts.40 Strategies for mitigating risks for fieldwork participants should be more widely shared and adapted to local contexts. For example, the first author should not have been such a visible presence in the local indigenous activist community in Guatemala given the undercurrents of ethnic violence in the region. Meetings to understand and support health as a human right in this area should have been discreet and locally driven. Fieldwork training must also grapple with the more elusive questions of positioning of the self while in the field and afterward, and how to navigate engagements with local moral worlds that may clash with one’s own. Ultimately, fieldworkers must strike a balance of doing neither too much nor too little while embedded in project communities. Engagement with a practical ethical framework can help individual fieldworkers and the field of global health become more confident that in-the-moment decisions in the field are ethical ones that minimize risks.

Finally, we must create space for routinely reporting fieldwork ethics issues in a way that goes beyond the procedural or punitive. Publications and presentations of global health work should be expected to include the dynamics and challenges of the fieldwork that produced the data or program outcomes being reported. The important shift in global health toward increased rigor in process evaluation and the turn in human rights to medical and scientific empiricism can serve as vital points of entry for explicitly including fieldwork realities in project reports. By doing so, we can bridge the current gap between fieldwork experiences and outcomes, good and bad, and the ethical principles and goals of promoting the right to health that underpin contemporary global health. The social sciences have well-developed methods for incorporating useful fieldworker self-reflection alongside qualitative data that could be profitably incorporated into the publication of global health projects.41 Regular reporting and discussion of fieldwork experiences alongside the traditional scientific data would enable an ongoing inductive process to map fieldwork challenges and share strategies for managing fieldwork risks.

Conclusion

Unintended, sometimes terrible, consequences can come from global health fieldwork or documenting human rights abuse. These consequences can affect individual local collaborators, project communities, fieldworkers, and the humanitarian programs and institutions that global health seeks to advance. Global health and human rights as empirical undertakings must more fully acknowledge the risks and dangers brought by fieldwork, the unequal experiences of these risks that local partners and foreigners may face, and the ways in which fieldwork realities shape documentation, research, and project implementation. With this article, we aim to open a conversation through which the field experiences of others in challenging or risky places can be discussed and meaningfully analyzed. Implementation of a global health ethics practice framework would institutionalize explicit attention to considering fieldwork ethics, providing training on fieldwork risks and sharing ethical challenges arising from fieldwork. The framework should be centered on our dual responsibility to understand and prevent the risks to project participants and fieldworkers. This framework would be useful in training and supporting fieldworkers and the communities in which they work, drawing together the diverse disciplinary fields that contribute to the work of global health and the advancement of access to health care as a human right. Through an ongoing and iterative process of applying the ethics practice framework, the interdisciplinary endeavor of global health can build an experiential evidence base for the types of fieldwork challenges encountered and create best practices for managing fieldwork risks.

Acknowledgments

The first author thanks Jonathan Maupin, Peter Rohloff, Martha Rees, and Chris DePree for input on the development of this article. The second author thanks Asfandiar Shukri, Howard Hu, and colleagues at Physicians for Human Rights for verifying the current safety of the refugees visited in 1988 and their feedback on the ideas in this article.

Rachel Hall-Clifford, MPH, MSc, PhD, is an associate professor of anthropology and public health at Agnes Scott College in Georgia, USA, and director of the National Association for the Practice of Anthropology – Occupational Therapy Field School in Guatemala.

Robert Cook-Deegan, MD, is a professor at the School for the Future of Innovation in Society and at the Consortium for Science, Policy and Outcomes at Arizona State University, USA.

Please address correspondence to Rachel Hall-Clifford. Email: rhallclifford@agnesscott.edu.

Competing interests: None declared.

Copyright © 2019 Hall-Clifford and Cook-Deegan. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

References

  1. S. M. Holmes, “Is it worth risking your life? Ethnography, risk and death on the US–Mexico border,” Social Science and Medicine 99 (2013), pp. 153–161; Rylko-Bauer, L. M. Whiteford, and P. Farmer,“Prologue: Coming to terms with global violence and health,” in B. Rylko-Bauer, L. M. Whiteford, and P. Farmer (eds), Global health in times of violence (Santa Fe, NM: School for Advanced Research Press, 2009); S. L. Pigg, “On sitting and doing: Ethnography as action in global health,” Social Science and Medicine 99 (2013), pp. 127–134.
  2. A. Kleinman, “Four social theories for global health,” Lancet 375/9725 (2010), pp. 1518–1519.
  3. C. Beyrer and N. E. Kass, “Human rights, politics, and reviews of research ethics,”Lancet 360 (2002), pp. 246–251.
  4. J. F. Childress, R. R. Faden, R. D. Gaare, et al., “Public health ethics: Mapping the terrain,” Journal of Law, Medicine and& Ethics 30/2 (2002), pp. 170–178; N. E. Kass, “Public health ethics: From foundations and frameworks to justice and global public health,” Journal of Law, Medicine and Ethics 32/2 (2004), pp. 232–242.
  5. G. Stapleton, P. Schröder-Bäck, U. Laaser, et al., “Global health ethics: An introduction to prominent theories and relevant topics,”Global Health Action 13/7 (2014).
  6. Kass (see note 4).
  7. L. M. Whiteford and C. Vindrola-Padros, Community participatory involvement: A sustainable model for global public health (Walnut Creek, CA: Left Coast Press, 2015); J. V. Lavery, P. O. Tinadana, T. W. Scott, et al., “Towards a framework for community engagement in global health research,” Trends in Parasitology 26/6 (2010), pp. 279–283.
  8. B. Pratt and A. A. Hyder, “Applying a global justice lens to health systems research ethics: An initial exploration,”Kennedy Institute of Ethics Journal 25/1 (2015), pp. 35–66.
  9. G. M. Lairumbi, M. Parker, R. Fitzpatrick, and M. C. English, “Ethics in practice: The state of the debate on promoting the social value of global health research in resource poor settings particularly Africa,” BMC Medical Ethics 12/1 (2001), p. 22.
  10. C. Myser, “Defining ‘global health ethics’: Offering a research agenda for more bioethics and multidisciplinary contributions-from the global south and beyond the health sciences-to enrich global health and global health ethics initiatives,”Journal of Bioethical Inquiry 12/1 (2015).
  11. P. Bourgois, “Confronting anthropological ethics: Ethnographic lessons from Central America,”Journal of Peace Research 27/1 (1990), pp. 43–54.
  12. P. Redfield, “The impossible problem of neutrality,” in E. Bornstein and P. Redfield (eds),Forces of compassion: Humanitarianism between ethics and politics (Santa Fe, NM: School for Advanced Research Press, 2011), pp. 53–70; S. R. Benatar, “Global health and justice: Re‐examining our values,” Bioethics 27/6 (2013), pp. 297–304; E. Stover and H. Weinstein, “Health, human rights, and ethics,” Cambridge Quarterly of Healthcare Ethics 10/3 (2001), pp. 335–335.
  13. S. Keshavjee, Blind spot: How neoliberalism infiltrated global health(Oakland: University of California Press, 2014).
  14. N. Daniels, Just health: Meeting health needs fairly (Cambridge: Cambridge University Press, 2007).
  15. P. W. Van Arsdale and D. R. Smith,Humanitarians in hostile territory: Expeditionary diplomacy and aid outside the Green Zone (New York: Taylor and Francis, 2010).
  16. D. Fassin, Humanitarian reason: A moral history of the present (Berkeley: University of California Press, 2011).
  17. P. Farmer and N. Gastineau, “Rethinking health and human rights: Time for a paradigm shift,” in M. Goodale (ed). Human rights: An anthropological reader (Oxford: John Wiley and Sons, 2009).
  18. C. Han, “The difficulty of kindness: Boundaries, time, and the ordinary,” in V. Das, M. D. Jackson, A. Kleinman, and B. Singh (eds), The ground between: Anthropologists engage philosophy (Durham, NC: Duke University Press, 2014).
  19. M. R. Hunt, L. Schwartz, C. Sinding, and L. Elit, “The ethics of engaged presence: A framework for health professionals in humanitarian assistance and development work,”Developing World Bioethics 14/1 (2014), pp. 47–55; A. D. Pinto and R. E. Upshur, “Global health ethics for students,” Developing World Bioethics 9/1 (2009), pp. 1–10.
  20. Kleinman (2010, see note 2).
  21. P. Redfield, “The unbearable lightness of expats: Double binds of humanitarian mobility,”Cultural Anthropology 27/2 (2012), pp. 358–382.
  22. C. McInnes, A. Kamradt-Scott, K. Lee, et al., “Framing global health: The governance challenge,”Global Public Health 7/Suppl 2 (2012).
  23. R. Hall-Clifford, personal communication (2010).
  24. Ibid.
  25. H. K. Heggenhougen, “Planting ‘seeds of health’ in the fields of structural violence: The life and death of Francisco Curruchiche,” in B. Rylko-Bauer, L. M. Whiteford, and P. Farmer (eds),Global health in times of violence (Santa Fe, NM: School for Advanced Research, 2009), pp. 181–200.
  26. Physicians for Human Rights, Winds of death: Iraq’s use of poison gas against its Kurdish population (1989). Available at http://physiciansforhumanrights.org/library/reports/iraq-winds-of-death-poison-gas-kurds-1989.html.
  27. P. Spicker, “Research without consent,”Social Research Update 51 (2007), pp. 1–4.
  28. Bourgois (see note 11); Rylko-Bauer et al. (see note 1).
  29. Holmes (see note 1).
  30. A. C. G. M. Robben, and C. Nordstrom, “The anthropology and ethnography of violence and sociopolitical conflict,”in A. C. G. M. Robben and C. Nordstrom (eds), Fieldwork under fire: Contemporary studies of violence and survival (Berkeley: University of California Press, 1995), pp. 1–21; C. W. Watson (ed), Being there: Fieldwork in anthropology (London: Pluto Press, 1999); N. Scheper-Hughes and P. I. Bourgois, “Introduction: Making sense of violence,” in Violence in war and peace (Oxford: Blackwell, 2004); A. McLean and A. Leibing (eds), The shadow side of fieldwork: Exploring the blurred borders between ethnography and life (Oxford: Blackwell, 2007).
  31. T. Williams, E. Dunlap, B. D. Johnson, and A. Hamid, “Personal safety in dangerous places,”Journal of Contemporary Ethnography 21/3 (1992), pp. 343–374.
  32. L. Green, “Living in a state of fear,” in A. C. G. M. Robben and C. Nordstrom (eds), Fieldwork under fire: Contemporary studies of violence and survival (Berkeley: University of California Press, 1995), pp. 105–128.
  33. R. Chierici, “Falling into fieldwork: Lessons from a desperate search for survival,” in A. McLean, and A. Leibing (eds),The shadow side of fieldwork: Exploring the blurred borders between ethnography and life (Oxford: Blackwell, 2007), pp. 204–218.
  34. A. Kleinman, What really matters: Living a moral life amidst uncertainty and danger (Oxford: Oxford University Press, 2006).
  35. Robben and Nordstrom (see note 30), p. 13.
  36. C. Simon and M. Mosavel, “Getting personal: Ethics and identity in global health research,”Developing World Bioethics 11/2 (2011), pp. 82–92.
  37. L. H. Malkki, The need to help: The domestic arts of international humanitarianism (Durham, NC: Duke University Press, 2015), p. 53.
  38. P. A. Singer and S. R. Benatar, “Beyond Helsinki: A vision for global health ethics,”British Medical Journal 322/7289 (2001), p. 747.
  39. L. London, “Ethical oversight of public health research: Can rules and IRBs make a difference in developing countries?”American Journal of Public Health 92/7 (2002), pp. 1079–1084.
  40. M. R. Hunt and B. Godard, “Beyond procedural ethics: Foregrounding questions of justice in global health research ethics training for students,”Global Public Health 8/6 (2013), pp. 713–724.
  41. J. Borneman and A. Hammoudi, Being there: The fieldwork encounter and the making of truth (Berkeley: University of California Press, 2009); A. P. Collins and A. Gallinat (eds),The ethnographic self as resource: Writing memory and experience into ethnography (New York: Berghahn Books, 2013); R. Behar, The vulnerable observer: Anthropology that breaks your heart (Boston: Beacon Press, 2014).